ML20236C731

Special Rept on Initial Operating History of Plant

ML20236C731
Person / Time
Site:	Vogtle
Issue date:	07/22/1987
From:	GEORGIA POWER CO.
To:
Shared Package
ML20236C734	List: ML20236C731 ML20236D042
References
NUDOCS 8707300172
Download: ML20236C731 (45)

Text

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ENCLOSURE i

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i SPECIAL REPORT ON THE INITIAL OPERATING HISTORY 1 0F PLANT V0GTLE UNIT 1 July 22, 1987 i i

ATTACHMENTS A. Reactor Trip Summary B. Engineered Safety Features Actuations Summary l

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SECTION PAGE i EXECUTIVE

SUMMARY

-I. 1 II.. . INTRODUCTION . . ... . . . . . . . . . . . . . . . . . . 3 III. OVERVIEW . . . . . . . . . .- . . . . . . . . . . . . .. . .

5 IV. ANALYSIS 0F OPERATING EVENTS . . . . . . . . .:. . . . . '9 l A. Scope of Analysis . . . . . . . . . . . . . . . . . . 9.

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B. Results of Analysis . . . . . -

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1. Feedwater/ Steam Generator Related Events' .... 9

2. Control Room and Containment Isolations . . . . . 12 3.: Other Operating Events ............. 13-V. PROGRAMS AND INITIATIVES . . . . . . . . . . . . . . . . 15 L A. . Organizational Enhancements ... . . . . . . . . . . . 15 I f ' 1. P_lintStaffAugment'ationandInitiatives .... 15.

2. Interdisciplinary CommunicationLImprovements .. 17.

3, Management and Staff ' Augmentation for

, Major Plant Evolutions . . . . . . . . . . . . 18 B. Plant'and Staff Program Enhancements ........ 18

1. -Root Cause Evaluation and Corrective Action Program ................ 18

2. Shift Operations Improvement Program ...... 19

.3. Positive' Control of Plant Valves ........ 20 q

4. Plant' Material Condition Improvement Program .. 21 C. Training Program Enhancements . . . . . . . . . . . . 22

1. . Lessons Learned . . . . . . . . . . . . . . . . . 23

2. Plant Specific Simulator Upgrade ........ 24 D. Management Overview and Assessment of Effectiveness . 25 I L 1. Quality Assurance Department .......... 25  ;

2. - Independent Safety Engineering Group. ...... 25  !

3. Safety' Review Board . . . . . . . . . . . . . . . 26

4. Senior Executive Participation ......... 27 ATTACHMENTS l A. Reactor Trip Summary i B. Engineered Safety Features Actuations Summary

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I LECTION I EXECILVfLliUbMARY Hithin the first five months of 1987, the Georgia Power Company -(GPC) received an operating license for Vogtle Unit 1, substantially completed the startup test program and declared the unit to be in commercial operation.

In this period, the primary reactor plant demonstrated, through thorough testing up to and including full power, that it would operate as designed.

Georgia Power attributes this achievement, under demanding conditions, to the significant contributions of Georgia Power personnel and its vendors and j suppliers.

Several systems in the secondary, non-reactor, steam plant could not be tested fully at power prior to the production of substantial reactor heat and secondary plant steam. During the secondary plant power ascension testing,. a relatively large number of steam plant operational transients occurred, some of which were repetitive. Some of these secondary transients F also ' initiated reactor trips. In addition, other equipment and personnel \

problems led to engineered safety features (ESF) actuations and other events related to initial operations. It was the repetitiveness of these events that led to a concern by Georgia Power. Also, unpredictable component failures resulted in several reactor trips that were not related to other steam plant initiated shutdowns. During all trips, the reactor safety systems functioned properly in response to events or conditions that should have caused reactor shutdowns.

Although Georgia Power had anticipated operational problems such as these, and had exerted major efforts to preclude them, the corrective actions taken following some events were not fully adequate to prevent recurrence. This was disappointing and caused an assessment of many aspects of plant operations. In retrospect, more effort to assure better implementation of our operational preparedness efforts may have reduced the number of events during this period.

As trends in secondary plant test performance, and in overall plant operation, emerged, Georgia Power took prompt, aggressive action to change programs, incorporate lessons learned, redirect training and to modify staffing to improve performance. This required critical self-appraisals in order to ensure the identification of areas deserving of enhancement. The findings from these critical appraisals have been organized, for discussion purposes, into four target areas. These four target areas are organizational enhancements, plant and staff program enhancements, training program enhancements and management overview and assessment of effectiveness. Both short-term and long-term actions are in progress as a result of these initiatives.

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The report summarizes the operating history at Vogtle, analyzes the trends of events and describes both historical and ongoing initiatives in the four target areas. He have already realized short-term improvements as a result of these initiatives. He firmly believe that implementation of our initiatives will demonstrate that our concern, based on initial operations, has been adequately resolved.

Georgia Power remains dedicated to the safety ethic and philosophy that we demonstrated in the successful design, construction and testing of Plant Vogtle. _ As plant operations continue, we will continue to apply this philosophy in striving to achieve our goal of excellence in nuclear operations.

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6 SECTION II INTRODUCTION This report presents a critical self-evaluation of the startup and initial operating events that were experienced at Vogtle Unit 1 from low power licensing on January 16, 1987 to July 22, 1987. The scope of this evaluation includes automatic reactor shutdowns, engineered safety features (ESF) actuations and other noteworthy operating events.

Although this report is specifically submitted in response to the request of Mr. Steven Varga, Director, Division of Reactor Projects I/II, U. S. Nuclear Regulatory Commission, dated June 16, 1987, the actions taken are the direct result of Georgia Power Company's continuing attention to the plant's performance during the difficult startup period. As a result, substantial refinements in many of our programs, and in the implementation of all programs have occurred due to the lessons we learned. Although the individual events that constitute our initial operating history have been analyzed in detail and corrective actions taken, this report, as requested, focuses on our broader evaluations. This is considered appropriate in view of our meetings on May 20 and June 11, 1987, and the Licensee Event Reports we submitted on each event.

The report is divided into major sections and supporting appendices as follows:

1. The " Overview",Section III, provides a brief history of the licensing and operation of Vogtle Unit 1.

2. The " Analysis of Operating Events",Section IV, addresses our analyses of events for trends, patterns or clusters with similar attributes.

3. The " Programs and Initiatives",Section V, is a compilation of corrective efforts implemented by Georgia Power to remedy problems that were observed during the first months of operation. To facilitate proper understanding of the actions taken, the problems are also listed.

4. The " Reactor Trip Summary", Attachment A to this enclosure, provides information on automatic reactor shutdowns from receipt of the low power license to the date of this report - July 22, 1987.

5. The " Engineered Safety Features (ESF) Actuations Summary",

Attachment B to this enclosure, provides information related to ESF actuations from receipt of the low power license to the date of this report - July 22, 1987.

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Georgia Power recognizes and appreciates - the observations- that the NRC provided during startup and early operation. He consider the observations to have been . of benefit to the operation of Vogtle Unit 1. Although problems with equipment, procedures, personnel and organizational interfaces were expected during initial startup operations, the events experienced exceeded .. expectations =,d, accordingly, were disappointing.

Notwithstanding, and most importantly, lessons were learned and aggressive corrective actions were taken. . Also, without minimizing-the significance of our startup problems, the majority of the events relate to (1) the secondary steam plant which could not be properly tested until the reactor was at

~ power and-(2) to false or spurious electronic equipment signals.

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SECTION III OVERVIEW Plant Vogtle _is a two unit nuclear plant located along the Savannah River {

in ' eastern . Georgia. Each . unit' consists of a Westinghouse four . loop-pressurized water reactor (PHR) rated at 3411. megawatts' thermal (HHt) and a GE turbine-generator . rated :at 1157 megawatts electrical (MHe). The balance

of ' plant. (B0P) systems, or secondary systems, (i .e. . . . auxiliary - feedwater

. system,. condensate.. and main ~ feedwater system, and '-steam- _ systems; heating, u ventilation, and ' air-conditioning, (HVAC) systems; and other- supporting  !

systems)! as well as all major structures, were . designed by Bechtel . Power .!

1 Corporation. - Unit'l . received a. low ~ power license on January 16, 1987 . and a .  !

full . power-flicense onHHarch 16. 1987. Unit 1 - was declared -to ' be ' in l commercial . operation _on May 31, 1987 following : completion of' the .100-hour ,

iendurance 'run at 100Lpercent power

, . _ . In'. late 1984, Georgia Power took' positive measures to ensure' that Unit 1 had; been : properly. designed and constructed' and. would be operationally ready

, prior to issuance off an 1 operating license. This Readiness Review Program provided i'a systematic and disciplined' review of Georgia- Power's-implementation of . design', construction and operational preparation programs to1 furtner increase..our assurance that quality .related. activities -at Plant  ;

L Vogtle' had been properly accomplished.- The initial test program demonstrated  !

that: components and' systems operated in accordance with design requirements.

The projram was: conducted in two phases: . the preoperational . test program and theLpower ascension test program. _The preoperational . test program .was  !

' designed . to assure' that plant components and systems were ready for_- testing i and, operating activities. The preoperational test program ended ? with the commencement of-fuel loading on January 17, 1987.

The. power ascension test program was structured to provide initial-1 startup data. in .the areas of _ reactor core physics, instrumentation and I controls,. plant - transients, chemical control . and behavior of. the' plant's l radiological environment. 'The power ascension test program began with fuel loading and was. conducted in a safe, controlled.-manner . using' a series of increasing power levels at which various testing was' completed. Testing' at '

the: 30 percent. power . level was completed on April .15,1987; This testing was .!

the first opportunity to test the secondary (steam) plant at significant-power output levels.

I' Pertinent dates of the test program are shown in the following table: I L-5 ,

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Received Low Power License 1/16/87 0 Commenced Fuel Load 1/17/87 1 Completed Fuel Load 1/28/87 12 Commenced Precritical Testing 2/1/87 16 Initial Criticality 3/9/87 51 Received 100% Operating License 3/16/87 58 Initial Synchronization to Grid 3/27/87 69 Achieved 30% Power 3/31/87 73 Achieved 50% Power 4/15/87 88 Achieved 75% Power 4/22/87 95 Achieved 90% Power 5/12/87 115 Achieved 100% Power 5/27/87 130 Commercial Operation 5/31/87 134 The startup test program was completed substantially on schedule as a result of good test coordination, careful planning, absence of significant material problems, and good implementation by the operating staff. Following initial criticality, a series of low power physics tests was performed to verify that core performance characteristics were ' consistent with nuclear design predictions. Westinghouse nuclear test requirements were demonstrated as having been met, thereby allowing operation at up to the full licensed power level. Tests at each succeeding power level were conducted following evaluations of detailed core flux maps and power coefficient determinations.

This also included calibrations of the process instrumentation channels, adjustments to protection and control systems, and conduct of primary and secondary ' systems chemistry tests at each power level. The full range of testing conducted at Plant Vogtle clearly demonstrates the acceptability and safety of the reactor and primary systems.

It was within the secondary (balance of plant) systems that the majority of events occurred during the startup program. Such events, while detracting from the startup program, can not take away from the success achieved in l

accomplishing the objectives that were set for the startup program. As i contained in the Final Safety Analysis Report (FSAR), the program objectives l were to:

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1. Accomplish a controlled, orderly, and safe initial core loading. {

2. Accomplish a controlled, orderly, and safe initial criticality.

3. Conduct low-power testing sufficient to ensure that design parameters are satisfied and safety analysis assumptions are conservative.

4. Perform a controlled, orderly, and safe power ascension with testing terminating at plant rated conditions.

5. Provide sufficient testing of transient and accident conditions to veri fy safe operation during transient or accident conditions.

Several innovative programs and extensive training in advance of full power authorization contributed to the success of the startup testing program. These programs included extensive training on the Vogtle simulator (installed and operational in 1982), as well as innovative arrangements that enabled the operators to gain operating experience at similar plants at other utilities.

Prior to Vogtle's full power authorization, the nuclear industry had recognized that operating events and challenges to reactor safety systems must be minimized. This was a major concern to Georgia Power, which had participated in the Westinghouse Owners Group - Trip Reduction Assessment Program (WOG-TRAP) and had implemented various potential improvements in operating procedures and hardware.

As the startup testing program progressed, Corporate management oversight and involvement increased in direct response to repetitive reactor trips and ESF actuations. As previously stated, most of the events were initiated by transients in secondary systems that directly affected: (1) stability and control of steam generator water level, and (2) ventilation and automatic isolation of the control room or primary reactor containment due to false or spurious electronic equipment signals.

Because of the number of reactor trips and ESF actuations experienced during startup testing and initial commercial operations, Georgia Power j management recognized the need for a prompt and comprehensive reevaluation of I operating experiences of Plant Vogtle Unit 1. A multidisciplinary team of '

engineert,'and managers, including members of the Georgia Power Safety R9 view  ;

Board, was assembled. The initial history of Unit 1 was examined in detail.

The concerns stated during previous meetings with the NRC on this subject .

were incorporated in the evaluation, and historical insights and observations I of Nuclear Operations personnel in Georgia Power were considered. Corporate and site policies and procedures for evaluating events were also reviewed.

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3 h: J The results of this evaluation identified issues which are broadly stated below (corrective actions are stated in later sections of this report):

1. The number of reactor trips, ESF actuations andL other events that occurred at Unit .1 since issuance of the low-power license on

' January 16, 1987 is' disappointing. They do not reflect our goal of excellence in operations.

2. 'The events that gave rise to these concerns, however, did not represent unsafe operation of the plant. Furthermore, there were no Emergency Core Cooling System (ECCS) injections.

3. There were weaknesses- in management and personnel performance 1 related to organizational interfaces . interdisciplinary ,

relationships and in the operational implementation of _ established '

programs. Also, personnel performance weaknesses and lack of i experience .in secondary plant operation were identified.

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SECTION IV ANALYSIS OF OPERATING EVENTS A. SC_Qoe of Analvsh The following activities were part of the analysis of operating events:

1. Evaluation of organizational and staffing effectiveness.

2. Evaluation of events and the review of reports that documented events; e.g., Licensee Event Reports (LERs), Independent Safety and Engineering Group (ISEG) reports and post trip review reports.

3. Interviews and discussions with personnel directly involved and familiar with the technical details of events.

4. Solicitation of technical advice from vendors and consultants.

5. Evaluations of the experiences of other nuclear utilities.

6. Review of Georgia Power's corrective actions and actual implementation.

7. Review of Georgia Power policies, procedures and instructions.

B. Results of Analysis The analysis of plant operating events indicates that the majority of events were associated with either feedwater and steam generator water level control or with automatic isolation for some portion of the plant.

Beyond these two groups of events, only a small number of other transients resulted in LERs. These other transients were as a result of a faulty circuit board in the reactor protection system (2 trips), source range flux rate (1 trip), operator inattentiveness during startup (1 trip) and turbine generator trips (3 trips). These three categories are discussed below:

1. Feedwater/ Steam Generator Related Events The majority of reactor trips and ESF actuations that occurred were associated with transients that originated within the plant secondary systems, e.g. the steam, condensate and main feedwater, and steam generator level control systems. A total of 24 transients occurred during which steam generator levels exceeded either Hi-Hi l or Low-Low level setpoints. Fourteen reactor trips directly resulted from these transients.

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During the early part of Plant Vogtle's testing program, these transients were predominantly associated with operator difficulties i in controlling steam generator water levels. It was noted that i actual plant (e.g. instrumentation) response was . quite different than that modeled on the training simulator. Initial tuning of the -

main feedwater regulating valves (MFRVs), bypass feedwater l regulating valves (BFRVs), and steam dump valves was also ongoing at the time. The necessary cycling of these valves gave rise to a' 1 large number of significant level oscillations within the steam generators. ,l Operator feedback from lessons learned during this early period i resulted in a number of modeling changes to the training simulator. <

Additionally, recognizing the difficulty of the tasks involved, t

Georgia Power augmented the control room staff by adding an i experienced operator during startup dedicated solely to maintaining 1 l control of steam generator level related systems.

In the .latter part of the initial operating period, equipment  ;

failures either caused or contributed to a number of steam generator level related transients. These included the following:

a. Two transients were initiated by main feedwater (MFH) pump discharge check valve failures. These check valve failures were caused by a design deficiency that allowed the valve hinge pins to disengage from the disk on two occasions, allowing the .

disk to separate from the valve bodies. '

A redesigned hinge pin has been fabricated, installed and tested with vendor assistance.

b. One transient was initiated by a failed condenser hotwell level controller, which resulted in a MFH pump trip on low suction pressure. Following the pump trip, the steam generator levels decreased to the Low-Low level reactor trip and the Auxiliary Feedwater actuation setpoint.

The condenser level controller was repaired and verified to be functioning properly. In addition, the three condenser sight glasses have been provided with markings to identify the high, i normal (or zero) and low levels that correspond to those displayed in the control room.

c. On another occasion, a MFH pump tripped due to a failed hydraulic tubing connection. The pump trip also resulted in a reactor trip on Low-Low steam generator water level.

The faulty hydraulic tubing connection was replaced and similar connections were inspected to ensure adequacy.

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a d. On two occasions, problems with two pressure transmitters caused valves .toeither an resulting open, atmospheric relief generator in steam valve or the '. steam level dump-swells and feedwater isolations on Hi-Hi level.

The pressure transmitters have now been tested satisfactorily.

In addition to- the above, several procedural deficiencies contributed to a number of the transients and reactor trips. These included the following:

a. A lack of specificity was identified in.several procedures as to the power level - at which the operator is to transfer  ;

feedwater flow from the AFH system to the HFH system,' or from ,

the BFRVs to the MFRVs. On two occasions, operators attempted i to, trasfer feedwater flow at either too low or too high a power, level. -resulting in steam generator levels drifting to their trip setpoints..

These procedures have been revised to instruct the operator as to the optimum power level at which to make the transfers.

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b. ' An initial ' test program procedure did not. provide sufficient I instructions as _ to the necessary actions to take following an over-shoot in . reactor power during a test. Contributing to this' deficiency, the test procedure was also unclear as to adjusting the main turbine load limiter. As a. result of these-deficiencies, a power over-shoot occurred. The operators response, while correct, was not directed toward the prompt.

recovery of steam generator levels and the preclusion of the ensuing reactor trip.

Corrective actions were taken to clarify the test procedure to ensure that main turbine load limiter is correctly adjusted and appropriate operator actions are taken,

c. Another test program procedure instructed the operators to maintain steam generator levels on the high end of their operating band, thereby contributing to the steam generator level swell transient that occurred when a- atmospheric relief valve cycled.

After evaluating the event, operations personnel established a lower maximum level and completed the test with no further problems. The effect of swell, as a result of atmospheric relief valve lifting, was considered when establishing the new upper limit. Since this was a one time test, revision of the procedure was not considered necessary. The procedure will be reviewed for applicability to the startup testing of Unit 2.

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j In 'sumary, actions taken in response to .these events included a f

.more aggrecsive program of pursuing vendor .and industry experience 4

in dealing with the true root cause of events. Additional vendor experts have been brought in to advise operators 'and to ensure proper alignment and tuning of the steam .and' feedwater control systems. Georgia Power has- become a more active participant in the Trip Reduction and Assessment Program (TRAP) Subcommittee of . the ,

Westinghouse Owners Group (WOG). Revisions in the simulator '

mode!ing have been and are being made to cause the simulator to more i accurately mimic. actual plant response characteristics as - actually .

observed in. the testing program. In conjunction .with simulator  !

upgrades, operations management personnel have conducted a ' number of '

training / feedback sessions with plant operators to review the lessons learned aspects or these transients. As mentioned above, an j additional experienced licensed operator has . been assigned .to the j control room during. startup solely to maintain control of steam "

generator level related systems. ,

2. Control Roon and Containment Isolationi  ;

The second major category of events involved spurious signals from };

individual toxic gas and radiation monitors which resulted in  !

actuations of the control room and containment isolation systems. 1 None of the actuations were associated with the presence of actual  !

- hazards (either toxic gas or radiation) to the operators. A summary 'I of these actuations includes: j

a. From February 9, 1987 through May 26, 1987, . fourteen ' control room ventilation system isolations occurred as a result of spurious actuations of toxic gas monitors. Ten of these isolations occurred before full power authorization on March 16, 1987.

Several factors have contributed to the cause of these actuations. The monitors have been shown to be overly sensitive to the presence of gases other than chlorine, the primary toxic gas for which the monitors are calibrated.

Secondly, a relatively low setpoint (2 ppm) was utilized; the monitor's response is somewhat erratic at the low end of its' detection range. Finally, due to the above combination, difficulty was experienced in achieving and maintaining proper calibration.

The corrective actions included the implementation of monthly calibration checks, in addition to the monthly analog channel operability checks which were already being performed.

Additionally, Georgia Power is actively evaluating the adequacy of a higher trip setpoint (5 ppm) that will permit reliable  ;

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operation of the monitors. Since late May 1987, all

-i - significant sources of chlorine have been removed from the J- plant site. This action is temporary and permits' complete resolution of the calibration problem without subjecting control room personnel to unnecessary control room isolations due to spurious detector trips.

b. From February 23 through May 1,1987, actuation of the control

_, room ventilation system in the emergency mode (recirculation)

~1 occurred eight times. The cause of these actuations has been attributed to voltage transients in the vital power supply to radiation monitor 1RE-12116.

Early in 1987, a task iorce was establi>hed to resolve these events as well as other issues related to the Plant Effluent Radiation Monitoring System (PERMS). Several of the events were traced to a failed data processing module (DPM) which was subsequently replaced. One event was caused by .an I&C g

technician failiag to block a L?st signal during performance of a channel operability check. The root cause was identified as a failure. to follow plant procedures. Corrective actions were taken to counsel the I&C personnel and foremen on.the necessity of following plant procedures. The corrective actions taken have eliminated these spurious actuations.

c. On .four occasions prior t9 full power authorization, containment isolation - Phase "A" occurred. The first two containment isolations in February 1987 occurred due to a faulty circuit board in the data processing module for containment high range radiation monitor 1RE-0006. On March 4, 1987 both containment isolation Phase "A" and containment ventilation isolction occurred simultaneously on two separate occasions. Investigation confirmed that a voltage transient in the vital power supply to the affected monitors occurred during maintenance activities, e.g. , reenergizing the Safety Features Sequencer System (SFSS), causing the monitors to sense a loss of power and revert to their default positions.

The faulty circuit board has been replaced. However, long term corrective actions are being evaluated.

3. Other Ooerating Events Beyond these first two categories, only a small number of events resulted in LERs. Discussion of some of these events is presented below:

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a. Common characteristics were noted in the two reactor trips that occurred on April 29 and May 4,1987. The cause of these two trips was traced to a faulty circuit board sending erratic voltage signals to one channel in the reactor protection system. In each case one other channel in .the reactor-protection system had been purposely. tripped by plant personnel to perform calibration or surveillance testing in accordance with plant Technical Specifications and procedures. This

_ situation permitted one false signal to trip the reactor.

Following the second event, maintenance personnel installed voltage monitors within the reactor protection system, and were able to confirm the faulty circuit board as the root cause of tnese trips.

The identification and subsequent replacement of the faulty circuit board solved this problem.

b. Two manual reactor trips that occurred prior to critical e eration, are included in our LER submittals but ar' not considered to be truly indicative of a recurring probl em.

Inese trips, which occurred on June 20 and 25,1987 involved an overly conservative action specified in the Annunciator Response Guideline for a failure within the Digital Rod Position Instrumentation (DRPI) System. The procedure was inconsistent with the safety significance of a failed DRPI indicator channel and the plant Technical Specifications in that it specified an immediate reactor trip rather than increased monitoring (which is the correct action).

The procedure has been revised.

The remaining reactor trips or ESF actuations, not discussed above, were evaluated to be indepen6ent events whose only link to each other could be major LEP. cause codes such as equipment failure or personnel error. Information on automatic reactor trips and ESF actuations that occurred since issuance of the low power license is attached to this report. This information consists of a tabular summary of reactor trips and ESF actuations and graphic presentations that show the distribution of events by system / subsystem in which they occurred over time. In summary, this analysis confirmea that the majority of the other operating events were a result of a few underlying faults or conditions as identified.

Although nothing can be done to change the initial record of events, steps described in the next section were taken and will continue to be taken to ensure a significant reduction in the rate of occurrence of all events.

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9 fi SECTION V.

PROGRAMS AND INITIATIVES

• L Significant senior management involvement in. c.ur nuclear units is~ the

standard =methodcof; operation within- the Georgia Power Company. This level of involvement hase contributed: to the development and issuance off coordinated.

- programs 1 and. initiatives. : Several .of these ~ programs iand initiatives have.

been in - direct: response / to Lspecific~ problems to ensure. aggressive, effective -

and efficient management- of the processes 'that affect the safety and.

reliability of. Unit l's: operations.

AsL thelstartup program progressed and problems started' to be encountered, .

l- ' Georgia. Power -recognized < the need.for corrections in : several existing.

L programs and for_ new initiatives to : improve- various aspects" of' operations.

L Changes were made promptly;upon identification of'the need.

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~For discussion purposes, these corrective programs and .' changes 'are Jorganized into four broad categories: >

L A.' Organizational Enhancements  :!

B. Plant.and Staff Program Enhancements-C. Training Program Enhancements 0.> Management Overview and Assessment of Effectiveness. ,

The. programs in each category are. summarized as follows:

A. Organizational Enhancements

1. Plant Staff Augmentation anLT A itiatives Recent staff changes .have been made in Lselected management.

positions ' in order' to improve the implementation .of existing programs. These . permanent assignments include highly experienced management . personnel for the plant positions of:

Plant Support Manager; Chemistry and Health Physics ' Manager; '!

Security Manager; and Technical Assistant to the Vogtle Plant  !

Manager.

In amplification of these changes, we wish.to note that: i 1

a. The new Plant Support Manager, formerly the corporate L: Engineering Manager, will provide increased sensitivity to

. engineering and regulatory requirements, and the Georgia Power commitment to-full compliance.

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b. The new Manager, Health Physics and Chemistry, formerly, '

the corporate Radiological Safety Manager, will substantially strengthen our capabilities in resolving radiological and chemistry issues. ,

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c. The new i.echnical assistant to the Plant Manager, formerly I the Corporate Manager, ISEG, will proviae expertise in l problem identification and resolution and in implementing ISEG recommendations.

In addition to the above, a corporate office Licensing Manager has been assigned to evaluate the overall safety and licensing process at Plant Vogtle and to develop a plan to merge the various safety and licensing activities into consolidated programs which will more effectively assure that plant activities are conducted in full compliance with regulatory requirements.

In addition to augmented corporate support, plant management has been authorized to augment the plant staff as necessary to assure that our excellent goals are achieved. Examples of this commitment include:

a. Increased manpower devoted to the reduction of' outstanding maintenance work orders,

b. ' Increased participation in problem resolution and prevention by s endors with special nuclear expertise. For the foreseca' ole future, vendors will be available on a twenty-four hour basis for major equipment problems such as the main turbine and generator.

In concert with our staff and personnel resou ' augmentation actions, a number of other planning and mana, activities have been initiated or revised to assure bette srformance.

As examples:

a. A biweekly management meeting program has been itiated.

At this meeting all cognizant corporate and p' ant inagers

aeet and discuss, understand, and improve site p. ' grams and plans.

b. Reorgal.ization of the work planning group has been accomplished to provide for more involvement of engineering and maintenance staffs in resolving operational and equipment problems.

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c. An on-site Duty Manager program has been established.

This is an assigned-manager, on-site, responsible for overseeing administrative and management activities during weekends and non-day shift hours. At Plant Vogtle there is little or no change in operation and maintenance  ;

processes between the shifts. Full time coverage is i supported by all departments to ensure equipment availability is maximized to assure the highest level of safety and efficiency.

d. The Shift Manager concept has been augmented. Key supervisors are assigned to each shift. This focused augmentation of managerial resources is a mechanism to improve interfaces and communications and to share collective- knowledge of operations, plant problems, evolutions, deficiencies and deportability of events and conditions.

The Georgia Power Company recognizes the need to provide continuous attention to management issues and problems to assure prompt corrective actions are taken when appropriate.

He believe the management / personnel changes made in response to the events experienced during initial operations are responsive and appropriate for the concerns.

2. Interdisciplinary Communication Improvements During the startup testing phase, communications between the operating staff and maintenance and engineering staffs were too focused or limited to brin 0 to bear the expertise of the specialists on solving many types of operational problems.

Consequently, the ' experts were not adequately involved in several post-event. root cause determination.

A substantially improved process has been established to critique operating events. There now is increased involvement by engineering and by the NSSS and AE when appropriate, in root cause evaluations and in the determination of corrective actions, particularly in post-trip reviews. As stated earlier, a structured bi-weekly plant meeting on operations has been instituted. This meeting, similar to the bi-weekly outage meetings hcid at plant Hatch, will include all cog; izant corporate and plant managers.

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3. Manaaerial and Staff- Augmentation for Maior Plant Evolut10hi  ;

A Special Startup Detail, in addition to the normal crew, was created to ensure that the very best, experienced operators, l engineers and managers are useo during plant startups. These '

experts are assigned to supplementing positions in the' shift j organization such as: reviewing critical data,- ensuring l correctness of estimated critical rod position calculations, I checking valve position alignments, and being available to respond to the needs of the operating staff as mechanical, electrical or instrumentation and control issues arise. This special detail is stationed prior to reactor startup and remains on watch through completion of critical evolutions such as the transition to main feedwater system operation and in the loading of the turbine genwator. For the foreseeable future, during use of the special detail, trainees are not being allowed to manipulate plant controls.

B. Plant and Staff Procram Enhancements

1. Root Cause Evaluation and Corrective Action Program

a. Post-Trio Review Initial implementation of our post-trip review program resulted in identification of program weaknesses. Georgia Power was not satisfied because the reviews of the actions actually taken, in some cases, tended to be limited in scope. Post-trip reviews were changed substantially and are now conducted in a much more structured fashion by a multidi sciplinary team generally comprised of the Plant Manager.' Technical Assistant, the Engineering Superintendent, representatives from Operations, Nuclear Safety and Compliance, ISEG, and, as appropriate, Quality Assurance, NSSS and AE.

b. Boot Cause Evaluations The method of conducting root cause evaluations in post-event critiques has also been enhanced. Georgia Power has undertaken the development of a formal root cause evaluation process based on the techniques employed in the Management Oversight and Risk Tree (MORT) approach, the Human Performance Evaluation System (HPES), Kepner Tregoe methods and Causal Factors Charting.

This process is currently being applied by the Vogtle staff, and a formal procedure is near completion. When completed this procedure, like other improvements, will be applied to Plant Hatch.

18

c. Trio Reduction Program Extensive development' of several initiatives has been l encompassed in this program. The key elements of Vogtle's Trip l Reduction Program are the Post-Tri p Review Team, industry I programs, industry experience reviews and failure analyses. l Comprehensive root cause evaluations described elsewhere in l this report are an integral part of these reviews. The '

Independent Safety Engineering Group has been instrumental in developing and integrating these elements into the overall program. The post-trip reviews now being conducted, which were instituted as a result of operating events, have enhanced the quality and comprehensiveness of review activities and are a positive factor in reducing the likelihood of repetitive events.

d. Human Performance Evaluation System Late in 1986 Georgia Power initiated a review of the Human i Performance Evaluation System (HPES) as developed by the Institute of Nuclear Power Operations (INP0). This program had undergone several years of development, through two pilot programs, and had been implemented at numerous utilities. It was based upon a successful effort in the aviation industry (the Aviation Safety Reporting System) and showed considerable promise for Georgia Power Company.

The HPES program is a voluntary human performance situation reporting, evaluation, and dissemination program. Its objectives are to increase awareness of circumstances and factors contributing to and influencing human performance situations and then to improve performance based on lessons learned from recognition and evaluation of such situations.

Participation in and implementation of the program require personnc1 to complete a course of instruction at INP0.

In early 1987 Georgia Power Company arranged for attendance at the next convened class. A HPES class was attended by three Georgia Power employees. Georgia Power became the 24th utility to participate in the HPES program. Full implementation is now being effected with the development of appropriate procedures, advertising, and supporting administrative material.

2. Shift Ooeratiers. Improvement Program As the startup program progressed, several events indicated the need to enhance the conduct of control room activities. Of the many actions taken, the following are considered the more important:

19

4 a, .The' quality of. shift turnover has been. enhanced by l L improving board walk-down and by requiring. the expanded use of checklists to verify the position of controls.

I

b. The quality of log. entries is being upgraded to assist in shift turnover. -trending of plant activities and event reviews.  ;

c. Supervisors are required to be even more involved in the details of planned maintenance.

e

d. The number of personnel allowed in the control room at any one . time has been : reduced and actions taken to suppress the noise level. This . includes a revision 'to the y telephone arrangements to reduce the noise level,

e. Operator attentiveness to plant instrumentation has been increased through retraining and increased supervision.

f. AT Georgia Power's request, INP0 conducted an assistance ,

visit dire:ted at the conduct of control room activities i and plant operations. Actions are in progress to  !

incorporate INPO recommendations. Specific responsibility .l for implementing control- room enhancements has been i assigned and will be tracked on a continuing basis to completion. The progress in achieving full implementation is being reviewed by Corporate Managers on a bi-weekly basis until our geal of excellence has been achieved.

3. Positive Control of Plant Valves During the startup program, .it became apparent that controls  !

could be enhanced and better implemented to ensure plant valves 1 were in, and remained in, their proper position. In response l to several events, Georgia Power' established a multidisciplined review team comprised of members from Operations (both Vogtle and Plant Hatch), Quality Assurance, and the Independent Safety Engineering Group (ISEG). The objectives of this team were to review events in. which mispositioned valves ~ played a significant role, determine the root causes. of the mispositioning and provide detailed recommendations to achieve j improved controls. During the review, the team reviewed documents, interviewed operators, inspected plant equipment and administered practical examinations.

The results of this review assisted plant management in  !

formulating a number of corrective actions. The following are some of the changes that were implemented:

l

(

20 l l

a. A .special training session was presented to plant operators to ensure their ability to correctly identify a valve position.

b. All' valve locks in place during preoperational testing ,

have been recored, thus, voiding all keys in existence during the construction and preoperational phases,

c. A one-time special check of valve position was performed by assigned system engineer (s) and operations personnel.

d. The Quality Assurance organization has conducted an independent surveillance of valve positions.

e. A quarterly verification of correct locked valve positions was implemented,

f. As part of management overview, the on shift operations supervisor, shift supervisors and shift technical advisors are required to ooserve valve lineups on a random and continuing basis.

g. Maintenance personnel are now required to notify the control room if they repositioned valves during a maintenance activity, and maintenance procedures are being reviewed to assure restoration information. Additionally, completo valve lineups will be performed within clearances subsequent to maintenance activities.

h. The existing locked valve list is being expanded to include additional information to help operations personnel locate valves in a timely manner.

To ensure an enhanced level of valve control is maintained, a special verification program will be implemented. This program will, on a continuing basis, provide additional and independent assurance that effective controls are in place. Tnis program will be formally titled our " Positive Valve Position Program."

4. Plant Material Condition Improvement Program Several events during the startup program indicated a need for improved maintenance practices. Heaknesses in control of several maintenance technicians, both staff and verdors, contributed directly to several events. Others resulted from slow responses to abnormal plant material conditions. The following are some of the actions being taken to achieve improved performance in this important area:

21

a. Qualified . staff technicians will be responsible for all plant maintenance performed by vendors.

b. Both engineering and maintenance representatives will participate in event reviews to ensure correct evaluations are being made based on plant symptoms.

c. Structured lists have been prepared to assiire proper and coordinated priorities are assigned - to material problems.

For example, a list of the top twenty plant material problems requiring engineering action has been developed for management review and scheduling purposes. In a similar manner, out-of-service and out-of-commission..

components are itemized.

d. The backlog of maintenance work orders is receiving additional emphasis, with particular attention to the control room instrumentation. As as example' of this effort, the status of control room instruments has been improved by almost 50 percent within the past few weeks.

e. A structured program has been implemented to aggressively upgrade the plant material coordination. The program is being spearheaded by the Technical Assistant to the Plant Manager.

The General Manager is following this program through daily meetings and by means of an inspection program involving key site managers.

C. Trainina Proaram Enhancements The training programs which were used for the initial training of our operators and technicians were comprehensive, thorough and reflective . of the best available programs throughout the industry.

This training was further enhanced by the use of a plant specific simulator, and extensive plant participation at similar PHR facilities, including the licensing of six senior operators at similar PHR facilities. However, the initial performance at Plant Vogtle has been disappointing. As a result, we have re-examined our efforts and have instituted a program of immediate corrective actions. This program is a refocusing of our previous program with major emphasis on practical implementation. It is being based principally on more direct operational feedback and on placing more intensity on lessons learned from throughout the nuclear industry.

This program enhancement requires modification and expansion of existing and on-going programs and a further upgrade of the plant specific simulator. These efforts and resources are now being applied to these matters.

22

He wish to note that the special operational' demands of a startup program were recognized in late 1986.and significant ' effort was made to focus attention on these needs. This resulted in a significant' and active. program -which includes.' lessons learned and training program enhancements based on the particular needs of Plant Vogtle.

The following are examples of these efforts:

1. Lessons Learned

a. In November 1986, a steering group was formed to identify those additional actions that could be taken, based on 4 industry experience and- the experience of Plant Vogtle at that . time, to enhance plant operations during the startup program. The steering group. initiated . specialized i training in a number of areas including the.following:  ;

(1) Control room discipline (2) Proper shift relief techniques (3) Plant communications (4) Recognition and verification of valve position (5) Procedural adherence 4 These programs were'. well conceived. However, as noted- ,

earlier, our initial evaluation leads us to conclude that ,

the execution of the programs was less than enthusiastic l and the results were disappointing. This specialized '

-training.has been reactivated with renewed vigor.

b. A special course was implemented. based on our experiences which was designed to enhance the licensed operators,  ;

equipment operators, shift supervisors, and radwaste '

operators skill in valve operation .and valve position determination, i

c. A. significant source of lessons learned has been and is I derived from the performance at Plant Vogtle. Each reactor trip and event report is examined specifically for training deficiencies and for lessons learned. These lessons learned are incorporated into the appropriate training programs, including simulator training.

d. Operating experience indicated a need for training i n shift turnover briefings, root cause determinations, and the conduct of thorough and meaningful operator rounds.

This training is being performed.

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e. Many. industry ~ events were; occurring .which lacked Lthe Y

' significance ~ to require. immediate incorporation into ' the training programs, betL still hadc a less~on to be learned.

In. response to; this need, 'in; mid-1986 a program 1was m , , developed to: convey .these_ experiences'. to the Plant Vogtle=

! l staff. . This " program consisted of - prominent 1y' posting :.in .

several; locations throughout the : plant a' Georgia Power 7 developed bulletin. entitled "HH00PS" with information concerning selected and pertinent events.

f.- Experience. has reinforced. the .importance 'of visual presentations ~. which 'hasi resulted ; in .a . program of video I

presentation to' increase the audience and more effectively portray lessons learned from in-house events.

' Georgia - Power ' is: currently l involved .in;'the development of job-  :

' performance-based training programs' 'that ' meet the objectives . and ~l h ' guidelines:. set forth by INP0. .The creation of. these. programs '

requires:a detailed analysis. of each job to determine the specific skills . and; knowledge required for the job', followed by the design -

and -development : of job specific training materials and programs.

These programs will be implemented in the near future and willL be

. evaluated by INP0 in.1.988, leading to Accreditation by the National -

Nuclear Accrediting Board. .

2. ' Plant Soecific Simulator Uoarade Th'e > simulator was purchased . prior to. plant operations and. the "modeling" was based 'on generic responses rather zthan the' a'ctual plant. 'This restited in some operator. training that did not truly' duplicate the response of plant systems, i.e., steam j generator level control. A concerted effort to upgrade. the '

L

, . responses of Ethe plant specific . simulator .to more closely representL the actual plant is now being pursued. Specifically, .:1

. improvements have.already been made in: 1

a. source range instrument response

b. rod worth modifications

c. . steam ~ generator water level control logi_c changes

d. . malfunctions related to criticality and critical rod position calculations, i Hith the assistance- of the Electric Power Research ' Institutt  !

(EPRI) and . Westinghouse' Electric Corporation, additional "modeling" changes have been identified :and these changes are x being addressed on a priority basis.

)

l-11 1

-l 24 i

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D. Manaaement Overview and Assessment of Effectiveness Management overview, including the assessment of effectiveness, is part of the culture within the Georgia Power Company. Georgia Power has in effect, the Nuclear Operations Overview Committee of the Board of Directors. This Committee has been in existence for several years and meets at one of our nuclear plant two times per year. A second high level of management overview is being provided by the Nuclear Operations Management Overview Board and the Plant Vogtle Project Board. Members of these two Boards include the Chief Executive Officer and Chairman of the Board, and the President of 4 the Company.

, 1 l

l Other significant overview and assessment activities include the Quality Assurance Department, the Independent Safety Engineering Group, the Safety Review Board, and Senior Executive Participation in Plant Vogtle operational problems and activities, including reactor startup decisions. These activities are described in the following paragraphs. '

l. Quality Assurance Deoartment The General Manager - Quality Assurance, who until recently served as the Plant Support Manager at Plant Vogtle, is responsible for the Quality Assurance Program related to the l operation and maintenance of the plant in accordance with the requirements of the Quality Assurance Manual. The quality assurance organization is independent of Nuclear Operations l and, as such, reports directly to the Senior Executive Vice President. This Senior Executive Vice President is responsible for establishing the policies, goals and objectives of the Plant Vogtle quality assurance programs.

In order to ensure that safety-related, and other activities  ;

are performed in a controlled manner and documented to provide j objective evidence of cor.pliance with NRC regulations, '

policies, procedures and instructions have been implemented.

The General Manager - Quality Assurance implements an extensive audit program to demonstrate conformance and eports findings  !

on the effectiveness of these programs directly to the Senior 1 Executive Vice President. The quality assurance organization j is well staffed and sufficiently independent o oroperly {

provide independent assessments to executive manageme.... j

2. Independent Safety Engineering Grong l l

Georgia Power has fully embraced the fundamental concepts of an  !

Independent Safety Engineering Group (ISEG) as set forth in i

25

NUREG 0737. As evidence of this, although not required by the j NRC, Georgia Power established an ISEG group at Plant Hatch. '

That. group is fully operational and making substantial contributions 'to the safe and effective operation of Plant Hatch. In selecting the Independent Safety Engineering Group for Vogtle, technical experience and ability were our foremcst criteria. The nuclear experience of this group averages over twelve (12) years, two (2) hold master's degrees, three (3) are HORT certified, two (2) hold or have held SRO licenses, and one is a reactor' engineer. The person who was corporate ISEG Manager, to which the resident ISEG teams at Hatch and Vogtle reported, was reassigned on a permar.ent basis to Vogtle in June, 1987, to assume the role of technical assistant to the Plant Manager. ISEG sensitivity and concern, therefore, are well represented in Plant Vogtle line management. A replacement for the new open position of Corporate ISEG Mar.ager is being actively pursued.

Several major contributions have been made by ISEG since Unit 1 start-up; e.g., enhancement to valve position control and valve operations, improvements to maintenance work order (MW0) processing and material deficiency identification, and watch standing practices. In its role as independent reviewer for corporate management, ISEG identified a priority need for a unified, multidisciplined approach to root cause determinations. In coordination with Nuclear Safety and Compliance (NSAC), several improvements were also made in the event evaluation process.

Corporate support and involvement )n ISEG activities at both nuclear plants are prov.ided by setting and maintaining high standards, assuring good communications at appropriate decision levels, rotation of personnel to encourage personal development, and long term commitments to aggressively improve the aspects of our nuclear plants.

High level Corporate monitoring of key nuclear plant performance indicators is conducted. Any downward or adverse trend is addressed and corrective actions taken.

3. Safety Review Board The Safety Review Board (SRB) has received significant attention by the Georgia Power Company. The SRB consists of high level officers and managers of Georgia Power Company and Southern Company Services. The SRB members have exceptional background and experience in nuclear safety matters. The SRB it strengthened additionally by Subcommittees consisting primarily of top level, carefully selected, consultants who perform independent reviews of nuclear safety events.

26

s. ,

l:

The Georgia Power Company SRB has been conducting a strategic i overview of significant issues existing at . Plant Vogtle. '

Examples of issues reviewed include the . Security Program; the

-Heating, Ventilation, and A'r Conditioning Systems; control of valve' alignments;: and the radiation detection systems inside W containment. The strategic overview focused on programmatic 1 effectiveness and weaknesses including identification of the root causes, corrective. actions associated with~ the issues, and

.the schedule for completion of the corrective actions. 3 The . SRB strategic overview of: key programmatic areas will I continue and is being strengthened. by more comprehensive ad hoc reviews of. certain specific areas. ' Recently three areas have been . identified. and the SRB is conducting in-depth reviews. q They are: the post trip / post ESF review team, the root cause- .

analysis' program, and the Independent Safety Engineering i Group. Results of the in-depth reviews will be discussed in Safety Review Board meetings.and documented in their reports. -

The strategic overview by the SRB is. strengthened by the efforts of its Subcommittees which provide frequent detailed "

reviews of site Quality Assurance Reports, Plant Review Board Minutes, Reportable Events, NRC, Violations, Design . Change

(

Proposals, and other documents to identify deficiencies and programmatic weaknesses. Safety concerns and administrative weaknesses are brought to the attention of the SRB by either <

prompt notification or during quarter 1.y key issue briefings. to ensure that adequate management attention is applied.

4. Senior Executive Participation Although stated earlier, in conclusion we wish to reemphasize .

that direct and personal' involvement and formal participation  !

by Senior Management in the activities at our nuclear plants is the normal standard for the Georgia Power Company, I

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